What treatment options are available for a 76-year-old patient with severe anxiety related to health concerns, who is already taking 60mg duloxetine (Cymbalta) for depression?

From the Guidelines

For a 76-year-old with severe health anxiety who is already taking 60mg of duloxetine for depression, I recommend maintaining the current duloxetine dose and adding cognitive behavioral therapy (CBT) specifically focused on health anxiety, as the most recent and highest quality study suggests that adjusting the regimen after 8 weeks if there is little improvement in symptoms despite good adherence 1.

Key Considerations

• The patient's current duloxetine dose is appropriate for depression management and may need 2-4 more weeks to show full effect on anxiety symptoms.
• Given the patient's age, medication adjustments should be made cautiously to avoid adverse effects.
• Non-pharmacological approaches, including deep breathing exercises, progressive muscle relaxation, and mindfulness meditation, should be started first and used daily for 10-15 minutes.
• Regular follow-up every 2-4 weeks initially is important to monitor for side effects such as increased fall risk, cognitive changes, or blood pressure fluctuations.

Treatment Approach

• The choice of an anxiolytic should be informed by the adverse effect profiles of the medications, tolerability of treatment, and patient preference, as suggested by the American Society of Clinical Oncology guideline adaptation 1.
• A stepped care model should be used to tailor intervention recommendations based on variables such as current symptomatology level, presence/absence of DSM-V diagnoses, and patient preference.
• Psychological and psychosocial interventions should be derived from relevant treatment manuals of empirically supported treatments, and outcome measures should be used routinely to gauge the efficacy of treatment for the individual patient.

Monitoring and Follow-up

• The patient's status, therapeutic response, and adverse effects of antidepressant therapy should be assessed on a regular basis, beginning within 1 to 2 weeks of initiation of therapy, as recommended by the American College of Physicians 1.
• The patient should be monitored for the emergence of agitation, irritability, or unusual changes in behavior, which can indicate that the depression is getting worse.
• Regular follow-up is crucial to adjust the treatment plan as needed and to ensure the patient's safety and well-being.

From the FDA Drug Label

1. 3 Dosage for Treatment of Generalized Anxiety Disorder Recommended Dosage in Geriatric Patients In geriatric patients with GAD, initiate duloxetine delayed-release capsules at a dosage of 30 mg once daily for 2 weeks before considering an increase to the target dose of 60 mg/day.

The patient is already taking 60 mg of duloxetine for depression. For generalized anxiety disorder (GAD) in geriatric patients, the recommended initial dose is 30 mg once daily for 2 weeks before considering an increase to 60 mg/day. Since the patient is already at 60 mg/day, no increase is necessary. However, it is essential to note that the patient's current dose is already at the recommended target dose for GAD in geriatric patients.

• The patient's current dose of 60 mg/day is within the recommended range for GAD treatment in geriatric patients.
• No dose adjustment is necessary based on the provided information 2.

From the Research

Treatment of Anxiety with Duloxetine

• Duloxetine is a potent serotonin and noradrenaline reuptake inhibitor (SNRI) that has been shown to be effective in the treatment of generalized anxiety disorder (GAD) 3.
• In patients with GAD, duloxetine 60-120 mg once daily was effective in improving anxiety and functional impairment, and was generally well tolerated 3.
• The efficacy of duloxetine in the treatment of GAD has been demonstrated in several studies, including a study that showed duloxetine to be effective in preventing or delaying relapse in responders to treatment 3.

Dose and Tolerability

• The recommended dose of duloxetine for the treatment of GAD is 60-120 mg once daily 3.
• Duloxetine has been shown to be generally well tolerated, with most adverse events being of mild to moderate severity 3, 4, 5.
• Common adverse events associated with duloxetine include nausea, dry mouth, headache, constipation, dizziness, and fatigue 3, 4, 5.

Use in Elderly Patients

• Duloxetine has been shown to be effective in the treatment of GAD in elderly patients, with a study demonstrating that duloxetine was effective in patients with GAD who were aged ≥65 years 3.
• Another study demonstrated that duloxetine improved cognition and depression measures in depressed elderly patients 4.

Comparison of Doses

• A study comparing the efficacy and safety of duloxetine 60 mg and 120 mg daily in patients hospitalized for severe depression found that both doses were equally effective and had similar safety and tolerability profiles 6.
• Another study found that rapid dose escalation of duloxetine from 60 mg/day to 120 mg/day was safe and tolerable, with most adverse events being mild and transient 5.

Overall Efficacy and Safety

• A systematic review of 85 studies on the efficacy, safety, and tolerability of duloxetine found that duloxetine was effective and safe for the treatment of major depressive disorder, GAD, neuropathic pain, fibromyalgia, and stress incontinence urinary 7.
• The review concluded that the dual mechanism of duloxetine benefits the treatment of comorbid clinical conditions, and supports the efficacy, safety, and tolerability of duloxetine in short- and long-term treatments 7.